Cost-effectiveness of abdominal aortic aneurysm repair: a systematic review

OBJECTIVES: A systematic review of the cost-effectiveness of abdominal aortic aneurysm (AAA) repair was conducted. Although open surgery has been considered the gold standard for prevention of AAA rupture, emerging less-invasive endovascular treatments have led to increased interest in evaluating the cost and cost-effectiveness of treatment options. METHODS: A systematic review of studies published in MEDLINE between 1999 and 2005 reporting the cost and/or cost-effectiveness of endovascular and/or open surgical repair of nonruptured AAAs was conducted. Case series studies with less than fifty patients per treatment were excluded. RESULTS: Of twenty eligible articles, three were randomized controlled trials, twelve case series, four Markov models, and one systematic review. Regardless of time frame, all studies found that endovascular repair costs more than open surgery. Although the high cost of the endovascular prosthesis was partially offset by reduced intensive care, hospital length of stay, operating time, blood transfusions, and perioperative complications, hospital costs were still greater for endovascular than open surgical repair. For patients medically fit for open surgery, mid-term costs were greater for endovascular repair with no difference in overall survival or quality of life. For patients medically unfit for open surgery, endovascular repair costs more than no intervention with no difference in survival. CONCLUSIONS: Although conclusions regarding the cost-effectiveness of AAA treatment options are time dependent and vary by institutional perspective, from a societal perspective, endovascular repair is not currently cost-effective for patients with large AAA regardless of medical fitness.     

Aortic aneurysm in a 74-year-old man with coronary disease and obstructive lung disease: is double jeopardy enough?

A previous decision analysis examined a patient with severe CAD, diminished ventricular function, and an abdominal aortic aneurysm and also concluded that CABG followed by aneurysm repair was optimal. This patient, who had well-preserved cardiac function but severely compromised pulmonary status, stood to gain less from CABG than would a patient with more severe coronary disease, thus accounting for the "close-call" between the CABG-AAA and AAA only strategies. Nevertheless, the analysis did emphasize the benefit of aneurysm repair, whether done alone or after CABG. The analysis also highlighted the significant risk of aneurysm rupture the patient is exposed to while recovering from CABG surgery. The operative mortality risks of the two procedures are similar; thus, the patient's total operative risk is approximately doubled if he undergoes both procedures rather than aneurysm repair alone. The key question raised by the analysis is whether this double jeopardy is more than compensated by the degree to which prior CABG reduces both short-term cardiac risk at subsequent aneurysm repair and long-term cardiac mortality. For this patient, who had good cardiac function, the gains appeared sufficient to offset the interval risk of aneurysm rupture and the additional risk associated with a surgical procedures. THE REAL WORLD The patient indeed underwent and tolerated CABG, although he had a stormy prolonged postoperative course due to pulmonary failure. After discharge from the hospital, he declined readmission for repair of the aneurysm. We did not model that possibility, clearly an inadequacy in our tree. Some six months later, the patient was still alive and was, reluctantly, readmitted for aneurysmorrhaphy. At that time, however, his pulmonary function had deteriorated and both the anesthesiologist and the pulmonary consultant stated unequivocally that further surgery was now impossible. In retrospect, the expected utility of CABG without aneurysm repair (thus providing only a decrease in the long-term mortality risk from his CAD) would have been 1.95 (DEALE) or 2.06 (Markov) years. Sensitivity analysis revealed that, even if long-term cardiac risk were completely eliminated by CABG, immediate aneurysm repair would have been a better approach had the patient's physicians known he would be likely to refuse or not be a candidate for the second operation. In summary, although the patient's comorbidities did indeed place him at significant operative risk for either aneurysmorrhaphy alone or two sequential procedures, the benefits to be gained were shown to far outweigh the risks when compared with expectant observation.(ABSTRACT TRUNCATED AT 400 WORDS)     

Endovascular treatment of 2 patients with an aneurysm of the descending thoracic aorta]

Two men, aged 71 and 70, who had previously experienced an abdominal aneurysm were found to have thoracic aortal aneurysms of respectively 8 cm and 7.5 cm in length. For the first patient an endovascular operation was carried out due to a high operative risk: with the help of a radiograph, four endoprostheses were inserted into the thoracic descending aorta via the femoral artery, after which the aorta diameter became more normal. A month later, the patient died from persistent renal failure, which had developed as a result of the previously ruptured abdominal aneurysm. In the second patient with an aneurysm of the proximal descending aorta, a left decompensation arose following aortal clamping during open surgical repair. Ten weeks later an endoprosthesis was inserted via the femoral artery. A year later the aortal diameter had decreased to 6.5 cm; the patient functioned well. The insertion of an endoprosthesis in the thoracic aorta is a minimally invasive procedure in which the patient experiences little perioperative inconvenience.     

A Cost-Effectiveness Model Comparing Endovascular Repair to Open Surgical Repair of Abdominal Aortic Aneurysms in Canada

Objectives:  The primary risk of abdominal aortic aneurysms (AAAs) is rupture, which is associated with a high mortality rate. Elective surgical options for AAA include open repair (OR) and endovascular aneurysm repair (EVAR). EVAR is less invasive than OR, and therefore may have less surgical risk than OR. However, the graft used for EVAR is much more expensive then the graft used for OR.
Methods:  A decision model with a 10-year time horizon was used to assess the cost-effectiveness of EVAR versus OR. The primary outcome measure was quality-adjusted life-years (QALYs). The model incorporated the costs and benefits of both perioperative outcomes and postoperative outcomes. A systematic review was conducted to derive clinical outcome rates. Cost and utility model variables were based on various literature sources and data from a recent Canadian observational study. Parameter uncertainty was assessed using probabilistic sensitivity analysis.
Results:  In the base-case model, the incremental cost per QALY of EVAR was estimated to be $268,337, whereas the incremental cost per life-year was found to be $444,129. The incremental cost per QALY of EVAR remained above $295,715 under different assumptions of cohort age and model time horizon.
Conclusions:  Based on commonly quoted willingness-to-pay thresholds, EVAR was not found to be cost-effective compared to OR.     

Retroperitoneal haematoma seen on CT scan in 2 patients with abdominal symptoms, aneurysm of the abdominal aorta and normal haemodynamics

In 2 patients, men aged 73 and 66 undergoing physical and ultrasound examinations for complaints of abdominal pain, an aneurysm of the abdominal aorta (AAA) with a diameter of 7-8 cm was discovered. Both their blood pressure and heart rate were normal. The older man then underwent a CT scan as did the younger man after being observed overnight. They both proved to have a ruptured AAA. They were operated on and recovered well. It can be problematic to diagnose a ruptured AAA quickly in patients with abdominal and back pain, AAA on ultrasound and normal haemodynamic parameters. In this situation an emergency CT scan will visualize any retroperitoneal haematoma and the patient can undergo an emergency operation. If the CT scan does not show any rupture there is time for preoperative preparations before performing a semi-elective procedure.     

Four patients with aneurysm of the hepatic artery

Two men aged 73 and 71 years and 2 women aged 76 and 80 years were referred for a false aneurysm (the 3rd patient) or true aneurysm (the other 3 patients) of an extrahepatic portion of the hepatic artery. The first patient was asymptomatic, the third patient had a rupture in the biliary duct and the remaining 2 patients had upper abdominal pain. In the first 2 patients, the aneurysm was removed surgically and replaced with a venous interposition graft. The 3rd patient received a coated stent. In the 4th patient, the artery was occluded, after which hepatic circulation recovered spontaneously. Treatment was successful in all 4 patients. Aneurysm of the hepatic artery is identified increasingly more often due to the current capabilities of diagnostic imaging. Elective treatment is indicated if the diameter is > 2 cm due to the increased risk of rupture, which has been associated with mortality rates of up to 40%. Primarily, endovascular treatment should be considered by means of a coated stent or aneurysm coiling. For patients with compromised intestinal circulation, surgical elimination with venous reconstruction is the treatment of choice.     

From the Cochrane Library: ultrasonographic screening for abdominal aortic aneurysm in men aged 65 years and older: low risk of fatal aneurysm rupture

Abdominal aortic aneurysm (AAA) is present in 5-10% of men aged 65-79 years and is often asymptomatic. The major complication is rupture, which requires emergency surgery. The mortality rate after rupture is high: about 80% of those who reach the hospital and 50% of those undergoing emergency surgery will die. Elective surgical repair of AAA aims to prevent death from rupture; the 30-day surgical mortality rate for open surgery is approximately 5%. Currently elective surgical repair is recommended for aneurysms larger than 5-5 cm to prevent rupture. There is interest in population screening to detect, monitor and repair AAA before rupture. A Cochrane systematic review of 4 randomised studies involving 127,891 men and 9,342 women revealed a significant reduction in mortality from AAA in men aged 65-79 years who underwent ultrasonographic screening (odds ratio (OR): 0.60; 95% CI: 0.47-0.78). There was insufficient evidence to demonstrate a benefit in women. Men who had been screened underwent more surgery for AAA (OR: 2.03; 95% CI: 1.59-2.59). These findings should be considered carefully when determining whether a coordinated population-based screening programme should be introduced. A gap in the current research is the balance of benefits and risks in women. Furthermore, detailed studies are needed on how to best provide information on the potential benefits and risks to individuals who are offered screening, and on the psychological effects of screening on patients and their partners.     

Abdominal pain as a symptom of a late complication following endovascular treatment of an aneurysm of the abdominal aorta

A 72-year-old man presented with progressive pain in the left lower abdomen thought to be due to diverticulitis of the colon. Antimicrobial therapy had not reduced the symptoms. Four years before, during an endovascular procedure, the patient had been given a stent because of an abdominal aortic aneurysm (AAA). A CT scan showed a large retroperitoneal haematoma on the left side and an increased diameter of the AAA of 8.5 cm. X-rays showed a gap between the endovascular stent and the left iliac leg of the endoprosthesis. Due to the space between the two grafts, there was retroperitoneal leakage ofblood. In endovascular surgery this life-threatening situation is called a type III endoleak. The patient was operated immediately using the endovascular technique. Through the left femoral artery a new coated stent was positioned over the gap, which led to rapid recovery of the patient. Patients with abdominal pain and a history of a vascular endoprosthesis should be given a CT scan and plain radiography to exclude an endoleak.     

Traditional and novel risk factors for clinically diagnosed abdominal aortic aneurysm: the Kaiser multiphasic health checkup cohort study

BACKGROUND: Identification of risk factors for and early diagnosis of clinically significant abdominal aortic aneurysm (AAA) before rupture is vital to optimize outcomes in these patients. Our aim was to examine traditional and three novel potential risk factors (abdominal obesity, white blood cell count, and kidney function) for abdominal aortic aneurysm (AAA, comprising discharge diagnosis or surgical repair) in a large multiethnic population. METHODS: Cohort study (N =104,813) conducted at an integrated health care delivery system in northern California. RESULTS: After a median of 13 years, 605 AAA events (490 in men and 115 in women; 91 [15%] fatal) were observed. In multivariable analysis, factors significantly associated with risk of clinically detected AAA included male gender, older age, black race (inversely), low educational attainment, cigarette smoking (with dose-response relation), height, treated and untreated hypertension, high total serum cholesterol, elevated white blood cell count, known coronary artery disease, history of intermittent claudication, and reduced kidney function. A significant Asian race by gender interaction was found such that Asian race had a (borderline significant) protective association with AAA in men but not in women. CONCLUSIONS: Our findings confirm that major atherosclerotic risk factors, except for diabetes and obesity, are also prospectively related to AAA and suggest that elevated white blood cell count and reduced kidney function may improve risk stratification for clinically relevant AAA.     

Aneurysms of the abdominal aorta: a 20-year study.

One hundred and eighty-eight patients in whom the diagnosis of aneurysm of the abdominal aorta (AAA) was established after 1 January 1960 were followed until their deaths or to 31 December 1979. By the actuarial method, the cumulative 5-year risk of an intact aneurysm progressing to rupture was 35%; the observed 5-year survival rate for patients who had medical management for intact AAA was 30%, for patients who had elective surgery for AAA 74%, for patients who had emergency surgery for ruptured AAA 35%, and for those who did not have surgery for ruptured AAA 0%. Comparison of the non-operated and electively-operated groups of patients showed that the former was disproportionately weighted with older higher-risk patients, suggesting that the difference in survival rates for the two groups might be a reflection of patient selection rather than of surgical intervention. Comparison of the cumulative 5-year risk of rupture of an intact AAA with the cumulative 5-year mortality rate associated with elective surgery for intact AAA showed that elective surgery for intact AAA might be expected to result in a reduction in the cumulative 5-year mortality rates of patients with intact AAA.     

Acute abdominal and back pain in a patient with an aortic aneurysm and a duodenum perforation on CT-scan

An 82-year old man with a known aneurysm of the abdominal aorta (AAA) presented with a history of acute onset abdominal and back pain of a few hours. He was haemodynamically stable and had pain on pressure over the aneurysm. Ultrasound confirmed the AAA, but could not demonstrate or exclude rupture. Subsequent CT-scan confirmed a non-ruptured AAA and demonstrated a small, curvilinear, hyperdense structure thought to be a fish bone or chicken bone which had perforated the duodenum. On gastroduodenoscopy, a fish bone was found and removed. The patient's symptoms resolved completely within two days. In patients with a possible ruptured AAA, echographic or CT-scan investigations can confirm or exclude the condition thus avoiding unnecessary surgery. These investigations also gather preoperative data for potential endovascular reconstruction. Before the introduction of new visualization techniques a duodenum perforation resulting from the unnoticed swallowing of a sharp object could only be diagnosed by explorative laparotomy. Delay in diagnosis leads to high mortality.     

Relation of Common Carotid Artery Lumen Diameter to General Arterial Dilating Diathesis and Abdominal Aortic Aneurysms: The Tromso Study

In a cross-sectional, population-based study in Tromsø,Norway, the authors investigated correlations between lumendiameter in the right common carotid artery (CCA) and the diametersof the femoral artery and abdominal aorta and whether CCA lumendiameter was a risk factor for abdominal aortic aneurysm (AAA).Ultrasonography was performed in 6,400 men and women aged 25–84years during 1994–1995. An AAA was considered presentif the aortic diameter at the level of renal arteries was greaterthan or equal to 35 mm, the infrarenal aortic diameter was greaterthan or equal to 5 mm larger than the diameter of the levelof renal arteries, or a localized dilation of the aorta waspresent. CCA lumen diameter was positively correlated with abdominalaortic diameter (r = 0.3, P < 0.01) and femoral artery diameter(r = 0.2, P < 0.01). In a multivariable adjusted model,CCA lumen diameter was a significant predictor of AAA in bothmen and women (for the fifth quintile vs. the third, odds ratioswere 1.9 (95% confidence interval: 1.2, 2.9) and 4.1 (95% confidenceinterval: 1.5, 10.8), respectively). Thus, CCA lumen diameterwas positively correlated with femoral and abdominal aorticartery diameter and was an independent risk factor for AAA. aorta, abdominal; aneurysm; blood vessels; carotid arteries; ultrasonography     

腔内隔绝术治疗肾下型腹主动脉瘤24例疗效分析

目的 探讨腔内隔绝术治疗肾下型腹主动脉瘤的疗效、适应证及其并发症的防治.方法 回顾性分析2006年4月至2008年9月经CT血管造影或磁共振血管造影确诊为肾下型腹主动脉瘤24例患者的临床资料.切开双侧股动脉,经股动脉将覆膜支架置于肾动脉下方,支架自膨张开,使血流经人造血管流向髂总动脉.结果 支架植入全部成功,术后即刻造影20例无内漏,4例存在轻度Ⅰ型内漏.无支架移位,无脏器及双下肢缺血表现.术后6个月复查CT增强扫描示全部病例支架形态完好,动脉瘤消失,支架外血栓形成.结论 腔内隔绝术治疗腹主动脉瘤具有简捷、微创、并发症少、术后恢复快等优点,为老年患者治疗肾下型腹主动脉瘤的首选方法.

Abstract：

Objective To investigate the efficacy and the indication and the management of perioperative complications in treatment of infra- kidney abdominal aortic aneurysm (AAA) by using endovascular graft exclusion (EVGE). Methods From April 2006 to September 2008, 24 patients with infra- kidney abdominal aortic aneurysms were diagnosed by contrast-enhanced CT or MRI scan. Vascular access was obtained through the bilateral femoral artery after arteriotomy and stent-graft was deployed into AAA of below the renal artery to occlude the left over cavity of AAA. The stent- graft was extended and anchored to the both side wall of AAA, the blood flow enter into the arteria iliaca communis through the sten't.Results Stent-graft deployment was successfully performed in all the patients. Immediate aortography after the procedure showed no leakage in 20 patients and the type Ⅰ minor leakage in 4 patients. No stent movement or organ and both lower extremities ischemia was found at the early post operative stage in all the patients. Six months after the operation, in all the 24 patients, contrast-enhanced CT scan showed the disappearance of the aneurysm and thrombosis at the level of the stent. Conclusions EVGE is simple,minimally invasive,less complication and quick recovery after operation. Thus it becomes first choice for the treatment of AAA for the elder patients.     

Prevalence of and risk factors for abdominal aortic aneurysms in a population-based study : The Tromsø Study

In a population-based study of 6,386 men and women aged 25--84 years in Troms?, Norway, in 1994--1995, the authors assessed the age- and sex-specific distribution of the abdominal aortic diameter and the prevalence of and risk factors for abdominal aortic aneurysm. Renal and infrarenal aortic diameters were measured with ultrasound. The mean infrarenal aortic diameter increased with age. The increase was more pronounced in men than in women. The age-related increase in the median diameter was less than that in the mean diameter. An aneurysm was present in 263 (8.9%) men and 74 (2.2%) women (p < 0.001). The prevalence of abdominal aortic aneurysm increased with age. No person aged less than 48 years was found with an abdominal aortic aneurysm. Persons who had smoked for more than 40 years had an odds ratio of 8.0 for abdominal aortic aneurysm (95% confidence interval: 5.0, 12.6) compared with never smokers. Low serum high density lipoprotein cholesterol was associated with an increased risk for abdominal aortic aneurysm. Other factors associated with abdominal aortic aneurysm were a high level of plasma fibrinogen and a low blood platelet count. Antihypertensive medication (ever use) was significantly associated with abdominal aortic aneurysm, but high systolic blood pressure was a risk factor in women only. This study indicates that risk factors for atherosclerosis are also associated with increased risk for abdominal aortic aneurysm.     

Spiral computed tomographic angiography as a substitute for intra-arterial angiography of aorta and its branches

Until recently, intra-arterial angiography was the diagnostic method of first choice when pathology of the aorta or its branches was suspected. A disadvantage of this technique is that only the lumen of spaces with blood flow can be visualised and that the soft tissue surroundings remain (partly) invisible. Spiral computer tomographic angiography (CTA) has some major advantages compared with conventional angiography. The technique is less invasive and faster. Also, the soft tissue is imaged by CTA. In addition, computer reconstructions allow viewing from all directions without the limitations of overprojection. Spiral CTA is a suitable technique for imaging the thoracic part of the aorta: in case of dissection if transoesophageal echography is not available, in case of an aneurysm to determine the diameter and in case of rupture as a highly sensitive but not very specific examination technique. For imaging of the abdominal part of the aorta, spiral CTA may be considered. In case of an aneurysm or a possible rupture of this part of the aorta it is then possible to visualize the operation area and to choose the optimal approach. For the exclusion of stenoses in mesenteric arteries or in renal arteries, spiral CTA offers the advantage of non-invasivity. The technique is less suitable for demonstration of these stenoses and does not allow immediate intervention.     

Elective surgery for aortic abdominal aneurysm: comparison of English outcomes with those elsewhere

INTRODUCTION: The aim of this study was to quantify mortality after elective repair of abdominal aortic aneurysm (AAA) in England, and to compare English case fatality rates (CFRs) with those reported in the literature. PATIENTS AND METHODS: English Hospital Episode Statistics (HES) for the financial years 1998/9 to 2001/2, linked to death data, were analysed. A systematic literature search was undertaken to identify studies reporting CFRs after elective AAA surgery. The CFR in England was compared with these studies by using confidence intervals on the CFRs and funnel plot techniques. RESULTS: In the English study, elective repair of AAA was performed on 11,338 patients of whom 771 died within 30 days after surgery (6.8%). The literature search found 66 studies: 34 reported mortality rates that were within the 99% confidence limits of the English rates, 31 below, and one study above. DISCUSSION: The CFR after elective surgical repair in England within 30 days of operation (6.8%) was higher than expected from the literature. Differences between England and other countries in quality of care is one possible explanation for the findings, but other explanations are possible and are discussed.     

Opening Pandora's box: The experiences of having an asymptomatic aortic aneurysm under surveillance

Abdominal aortic aneurysm (AAA) is a ballooning-out of the aorta that does not normally give any symptoms. Undetected and untreated an aortic aneurysm can rupture, which in most cases is fatal. Mass screening of 65-year old men for the early detection of AAA and, in selected cases, operation seem to reduce mortality due to rupture, although, screening has not reduced the overall mortality in this group. In Västra Götaland, the southwest part of Sweden, screening for AAA amongst 65-year old men started in 2009. There are controversies within the medical community about the benefits and adverse effects of screening. In order to explore men's experiences of being screened and knowing they had an aortic aneurysm, we undertook a qualitative interview study with 15 men who in the screening programme were identified as having an aortic aneurysm and who were to be followed-up with annual ultrasonic examinations for an indeterminate number of years. The interviews were analysed for categories and themes using content analysis. The study found that the men were ambivalent about the knowledge that they had an AAA and about the follow-up monitoring. They appreciated having the knowledge but it was accompanied by worry, feelings of anxiety and existential thoughts about the fragility and finiteness of life. We recommend that before a screening programme is implemented, the psycho-social consequences should be thoroughly investigated. Participants should be given adequate and understandable information about the consequences of screening so that they can make an informed choice whether to participate or not.     

Chronic-contained ruptured aortic aneurysm: un unusual cause of back pain

Chronic contained rupture of abdominal aortic aneurysm is a rare event which can cause diagnostic difficulties. It can present as a chronic back pain and the delayed diagnosis and delayed surgical repair may compromise the final results. The outcome of urgent repair of a chronic contained leak is equivalent to that of elective aneurysm repair. We report a case of contained rupture of a small abdominal aortic aneurysm with delayed diagnosis, evaluated by computed tomography showing a beginning erosion of the lumbar vertebral body. The patient was operated on within 24 hours on admission with uneventful surgical outcome.     

Risk as feelings in the effect of patient outcomes on physicians' future treatment decisions: a randomized trial and manipulation validation

The present study tested predictions derived from the Risk as Feelings hypothesis about the effects of prior patients' negative treatment outcomes on physicians' subsequent treatment decisions. Two experiments at The University of Chicago, U.S.A., utilized a computer simulation of an abdominal aortic aneurysm (AAA) patient with enhanced realism to present participants with one of three experimental conditions: AAA rupture causing a watchful waiting death (WWD), perioperative death (PD), or a successful operation (SO), as well as the statistical treatment guidelines for AAA. Experiment 1 tested effects of these simulated outcomes on (n = 76) laboratory participants' (university student sample) self-reported emotions, and their ratings of valence and arousal of the AAA rupture simulation and other emotion-inducing picture stimuli. Experiment 2 tested two hypotheses: 1) that experiencing a patient WWD in the practice trial's experimental condition would lead physicians to choose surgery earlier, and 2) experiencing a patient PD would lead physicians to choose surgery later with the next patient. Experiment 2 presented (n = 132) physicians (surgeons and geriatricians) with the same experimental manipulation and a second simulated AAA patient. Physicians then chose to either go to surgery or continue watchful waiting. The results of Experiment 1 demonstrated that the WWD experimental condition significantly increased anxiety, and was rated similarly to other negative and arousing pictures. The results of Experiment 2 demonstrated that, after controlling for demographics, baseline anxiety, intolerance for uncertainty, risk attitudes, and the influence of simulation characteristics, the WWD experimental condition significantly expedited decisions to choose surgery for the next patient. The results support the Risk as Feelings hypothesis on physicians' treatment decisions in a realistic AAA patient computer simulation. Bad outcomes affected emotions and decisions, even with statistical AAA rupture risk guidance present. These results suggest that bad patient outcomes cause physicians to experience anxiety and regret that influences their subsequent treatment decision-making for the next patient.     

Endovascular stent-graft placement for vascular failure of the thoracic aorta

It still remains undetermined whether endovascular stent-graft placement (ESGP) is the optimal initial treatment for elective cases of thoracic aortic disease because of unknown long-term results. However, it is also recognized that ESGP contributes to better outcome as an initial treatment for aortic emergency, such as rupture, aortic injury, and complicated acute type B aortic dissection. Despite the fact that most patients are elderly, early mortality rates of ESGP are reportedly around 10% in cases of ruptured degenerative thoracic aortic aneurysm. Postoperative morbidity is also superior in ESGP compared with conventional open repair. Postoperative paraplegia has rarely occurred with ESGP. In cases of blunt aortic injury (BAI), other complications may also be present because of other serious injuries. ESGP has changed the surgical strategy for BAI and partially resolved some of the clinical dilemmas. Early mortality rate is almost zero when a stent graft can be placed before re-rupture. While BAI is a very good indication for ESGP, young patients need careful management and attention because of the unknown long-term outcome. In cases of complicated acute type B aortic dissection, the two main determinants of death, shock from rupture and visceral ischemia, could be managed by ESGP with or without conventional endovascular interventions. Recent reports disclosed less than 10% early mortality with ESGP for complicated acute aortic dissection. Even if the possibility of endotension remains, ESPG seems to be beneficial for these critical patients as the preferable initial treatment. The importance of close follow-up should be stressed to avoid some devastating late complications following ESGP.